How I manage thoracic tumors incorporating the supra aortic trunks

Elie FADEL

Disclosure

Speaker name: Elie FADEL

I do not have any potential conflict of interest

Thoracic tumors that may invade the SAT

requiring surgical resection

From the Lung:

From the mediastinum:

NSCLC: Upper lobes +++

Metastasis to the upper lobes

Thymoma

Primary Mediastinal germ cell tumors

Sarcoma / Pseudoinflammatory tumors

Thoracic tumors that may invade the SAT

requiring surgical resection

From the Lung:

From the mediastinum:

NSCLC: Upper lobes +++

Metastasis to the upper lobes

Sarcoma

Thymoma

Primary Mediastinal germ cell tumors

Surgical challenges due to the SAT invasion

Surgical approach:

SAT-cross clamping:

SAT replacement:

• Combined cervicothoracic approach

• Vessels control and replacement

• Enbloc resection of the tumor and the involved vessels

• Always necessary because the collateral network is ligated

• Most of the time end to end anastomosis (rib resection / short vessel length)

• Avoid synthetic graft when potentially contamineted operative field

• Think about postoperative radiation therapy (vein/pericardial patch…)

• Protective pedicled flap

• Should be as short as possible

• As tumor resection time may be long (complexity of the procedure) all the other involved

structures should be resected first and the specimen pedicled around the involved vessel

• If the vessel is a carotid artery, think about shunting

Preoperative workup•Evaluation of the tumor

•Evaluation of the patient’s functional status

•Histological confirmation obtained +++

•Local tumor spread: Neck and chest angio CT, flexible bronchoscopy, EBUS, duplex scanning,

angiography and phlebography, MRI (spine+++)

•Distant tumor spread: PET scan, cerebral MRI or CT

•Standard laboratory and respiratory functional tests

•Ventilation/perfusion scanning

•VO2 max

•Echocardiography

•Coronary angiography

•Right heart catheterization

Contra-indication to surgery

•Predictive inability to achieve complete resection

•Severe co-morbidities jeopardizing survival

cN2,N3 disease

Distant metastasis

Procedures should be performed only with curative intent according

to the well-established principles of oncologic surgery (en-bloc

surgery with microscopically tumor-free margins)

The multimodal treatment of locally extended thoracic tumors

Radiation

therapy

SurgeryNeoadjuvant Adjuvant

Chemotherapy

Surgical approachesMediastinal Tumors → Cervico-sternotomy Lung Tumors → Cervicothoracotomy

The Superior Sulcus

The anterior cervicothoracic approach (Dartevelle et al JTCVS1993)

Transclavicular Transmanubrial

Costo clavicular

space

Aortic resection and reconstruction

under CPB

*

**

Mediastinal Tumors

Mostly invade the venous trunks

Mediastinal tumorsContraindications to surgery

• Involvement of both phrenic nerves

• Involvement of both innominate vein

confluences

Germ cell tumor

Use of Cell saver and CPB?

Survival curves of patients with and without

subclavian arterial invasion

(p 0.01)

42%

25%

Radiation induced sarcoma

The contribution of reconstructive surgery: tight free flap

Conclusions Surgical resection of locally extended thoracic tumors to the supraortic trunks is

feasible with good longterm outcome provided:

These demanding procedures should be performed by skilled team in thoracic and

vascular surgeries

• Extended preoperative workup ruling out surgical contraindications: distant

metastasis, inabitity to R0 resection, functional compromise (phrenic

nerves…)

• Respect of oncological principles: enbloc resection with R0 margins

• Vascular reconstruction with the shortest clamping time